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The Perceived Problems
Healthcare providers and commissioners face multiple challenges. They increasingly recognise that the NHS must change the way it operates to effectively meet future challenges. Commonly held opinions dominate discussion – from a belief in rising demand for healthcare services, costs associated with technological and treatment advances, increasing public expectations and a funding gap of £30 billion.
Conventional Approach to Change
Conventional approaches adopt an internal activity and cost-reduction focus. They typically involve workshops to agree service models and action plans. These tend to be accompanied by artificial modelling of service capacity and staff resourcing which arrive at ‘optimum levels’ of activity ‘contacts’ that are then tested in workshop environments. Following this type of analysis, work is undertaken to standardise service processes so as to reduce variation and waste.
Inherent within this approach is a belief that there is a capacity problem; solutions can be found via workshops and abstract planning models that determine staff resourcing. Workforce planning often ensues to try and address the perceived problem of the ‘plateaued worker’. The logic equates to stable staffing levels and standardised processes which will lead to activity and cost reduction gains. Standardising processes typically take place in workshop environments, far are removed from where the real work occurs.
Yet, in service organisations, seeking to standardise processes often creates problems. In healthcare there is high variability of patient demand; standardising processes will only cause service performance to fall (as the standard offering fails to meet the natural variation in needs) and costs increase (as the service provider’s standard work leads to more activity creating additional process waste and rework).
Adopting a Different Tact for Better Results
To address these challenges I have pioneered a new and refreshing approach to healthcare analysis – the Consumption Demand Method™. The starting point for improved services at less cost rests on more intelligent use of data to inform future performance improvement through intelligent system and service redesign. This alternative approach to realising better healthcare services and less cost begins with looking at healthcare data differently, not from an activity but patient-centred perspective.
Unlike existing practice, this work establishes time-series data to understand the true nature of person-demand for acute services in order to better understand the root-cause(s) of service challenges facing healthcare commissioners and providers alike. From understanding patient demands it is possible to develop knowledge as to ‘who, where and why’ these demands exist in the first place and how best to meet them in order to provide more effective, person-centred services at less expense.
The Method is directly influencing commissioners and providers, helping to challenge conventional thinking about healthcare demand. A recent study of secondary healthcare demand reveals counter-intuitive truths about the true nature of service demand. Unlike activity-levels, patient-centred demand in secondary care is not rising, but entirely stable and predictable. This is bad but good news.
Rather the root-cause for increases in activity (and associated costs) lay in the inability to successfully design service responses based on genuine understanding of patient needs. This inability drives ‘amplification of demand’ from relatively small numbers of patients – the ‘vital few’.
I have utilised the Method to establish a series of ‘demand-led’ improvement projects. These include work in the following areas:
- Primary care transformation
- Delayed transfers of care (DTOC)
- Accident and emergency
- Referral time to treatment (RTT)
- Integrated diabetes service
- Sustained high-cost users
- Long-term conditions
- Out-of-hours provision
- NHS 111
Moreover, the Method has also been successfully used to perform wide-ranging reviews of medical specialities and existing improvement schemes. One such review of a two-year QIPP scheme in paediatric urgent care, which cost seven figures to resource, found that the local healthcare economy would have saved more money by not doing anything! The work analysed demand for services against stated project aims, proposed changes in both design and process and realised operational savings.
The approach and work also acts as a catalyst in providing knowledge and skills transfer to senior clinicians, commissioners and specialists in the analysis of consumption data and redesign of service models and care systems against patient-level demand as opposed to arbitrary and abstract activity indicators.
In fact, the Method effectively identifies ‘business gaps’, encourages thinking about the real problems, asks intelligent questions and provides the means to sustainably improve performance. It deliberately keeps abstract programme and project management, risk assessments and associated document reporting to a minimum as they impede real change.
More intelligent use of data in this way can better inform future commissioning and operational improvement through system and service redesign. After all the NHS has exhausted all other misguided approaches – standardising; over-medicalising; functionalising and commercialising operations. We need to humanise healthcare and focus as much on care needs as medical treatments.
For more information see Front-to-Back Thinking – humanising healthcare – Dibley Consulting or contact me at firstname.lastname@example.org
In healthcare we obsess with the wrong perspective – I call it ‘back-to-front’ thinking and it drives all NHS healthcare activity. It begins with asking the wrong questions of data, fixating on activity levels and volumes. The logic is as simple as it is unthinking: every annual budget cycle; we try to reduce costs by reducing XX% activity. The one problem with this approach – it never works. Costs spiral ever upwards whilst service outcomes either flat-line or reduce.
In NHS language this results paradoxically in an “over-performance” problem (which sounds positive but is in fact bad) – doing more activity than was stipulated in the contract plan. Consequentially, this leads to a counter-productive reliance on confrontational contracting as the primary commissioning lever. ‘Quality guru’ Brian Joiner refers to this type of behaviour as distorting the figures and the system. Everybody loses. We can’t afford to continue working in this manner.
In fact, it doesn’t have to be this way. There is an approach that is as different as it is revolutionary and has the potential transform healthcare. It can provide commissioners and providers with the wherewithal to achieve meaningful and sustainable change. The better alternative – what I call ‘front-to-back’ thinking is to start with looking differently at the data (as well as using innovative methods to generate new patient-centred data).
‘Front-to-back’ involves studying the nature demand for healthcare services not from the perspective of arbitrary activity numbers but real patients over time-series data. What this typically reveals is that the problem acute trusts think they have – one of rising demand is not actually true. The real problem is what I call ‘boomerang’ demand: comparatively small numbers of patients consuming disproportionate amounts of activity and resource as a consequence of services that are not designed for them.
Asking ‘front-to-back’ questions allows you to study the nature of activity that takes place on patients – how much is good versus wasted work; how much can be redesigned to work differently; how much activity actually should take place at different times, in different ways or not at all! Utilising this approach and its way of thinking then allows healthcare providers and commissioners the knowledge to undertake ‘intelligent system and service redesign’ around cohorts of patients not abstract service pathways.
The holy-grail of better services at less cost is achievable in health but it requires a different way of thinking and then acting based on what empirical data, not opinion, tells us. We can do much better than have to continuously rely on and fail with activity management approaches. Activity obsession disorder is a serious but curable management condition.
Benchmarking has some merits in demonstrating ‘big-picture’ cost comparisons. But it is poor at understanding context, value and total costs. Moreover, it can’t provide the means to understand and improve performance. With benchmarking, it’s important to know what you are comparing; and if what you are comparing is actually comparable at a finer level of analysis e.g. disease conditions. Otherwise it’s like contrasting apples and pears.
Take the argument around using Dr Foster’s standardised measuring of mortality. Professor Nick Black was asked to look into mortality rates following a review by Sir Bruce Keogh in July 2013 found failings in care at 14 hospitals with the highest death rates. Professor Black argues that the two principal mortality measures are not an accurate indicator of poor care and should be ignored. Death statistics as influences of hospital care quality is a very ‘weak signal’ at best or a ‘distraction’.
One of these is Hospital Standardised Mortality Rates (HSMR). HSMR looks at the expected rate of death with actual rates. HSMR is a very dubious overall measurement of mortality – the numbers being influenced by the way hospitals collect data, changes in coding can alter mortality statistics. HSMRs do not take account of factors including the availability of hospice care – less hospice care is likely to lead to more people likely to die in hospital but be no reflection on the quality of acute care.
This can result in misunderstanding data e.g. Royal Bolton Hospital following a Dr Foster benchmarked audit is a case-in-point. It is worth a listen: BBC Radio 4 File on 4 Programme